Does Obama's 2013 Budget Herald the End of PEPFAR?

A sense of disbelief washed over the global AIDS community last month when President Obama unveiled his fiscal year 2013 budget proposal to cut $563 million from the President's Emergency Plan for AIDS Relief (PEPFAR) program. Cuts of this magnitude could lead to half a million people being denied lifesaving treatment, and countless preventable new infections. Shock and dismay have since given way to frustration; some feel the administration is signaling that an era of U.S. leadership in the global fight against AIDS may be coming to an end.

Since 2003, PEPFAR has been the most efficient and effective global health program in U.S. history. At its outset, millions of people living in sub-Saharan Africa and other low- and middle-income countries were dying of HIV without any hope of access to lifesaving antiretrovirals (ARVs). Entire communities were ravaged by disease, a generation of children was orphaned, and funeral homes could not keep up with demand. The vigilant work of activists brought these images and stories of horrendously suffering people to the world's attention. When President George W. Bush decided to make the global fight against AIDS an administration priority during his first term in office, PEPFAR was welcomed with unparalleled public and bipartisan congressional support.

By the end of President Bush's tenure, PEPFAR was arguably his administration's only foreign policy success. Two million men, women, and children had been put on treatment, over a million lives had been saved, untold numbers of new infections had been averted, and a quarter of a million children had been born free of HIV. Although the program was not without its flaws, the public and Congress were proud of the achievements made by PEPFAR and felt committed to build on its successes. In 2008, the program was reauthorized for five more years, again with bipartisan support.

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When President Obama came into office, one of the first things he did was appoint Dr. Ezekiel Emanuel, a bioethicist at the National Institutes of Health (NIH), as chief special adviser on health issues. Soon after, an internal discussion was advanced about the future direction of U.S. global health programming. The question posed was: How could the Obama presidency make its own mark on global health and differentiate itself from its predecessor's successes? Less than a year later, in May of 2009, President Obama announced the creation of the Global Health Initiative (GHI), a comprehensive realignment of U.S. global health aid and development strategy. The aim of GHI was not necessarily to strengthen or build on PEPFAR, but rather to "broaden the U.S.'s involvement in global health." In other words, the administration decided it was time to move away from the fight against AIDS and to invest in other global health diseases that could be fought, prevented, or eradicated at a lower cost. Following the launch of GHI, the Obama administration began distancing itself from PEPFAR by referring to the fight against AIDS as a "shared responsibility" and by insisting that the program needed to focus on "greater efficiencies."

Some efficiencies -- such as the promotion of comprehensive sex education, the removal of the global ban on syringe-exchange funding, better integration of TB/HIV services, and a refocusing of efforts on marginalized groups -- were obviously needed and long overdue. However, one critical efficiency -- drug pricing -- that the administration has more control over than it would like to believe, could in fact be the biggest factor in the perceived lack of shared responsibility by low-income governments. For over a decade now, AIDS activists have been fighting the impact that intellectual-patent barriers have on access to essential medicines. At times, the administration's own trade policy has undermined its purported goal of greater cost efficiencies. Government officials, civil-society organizations, and clinicians from Thailand, Brazil, India, and Ecuador to name a few, have lamented how U.S. trade policy has interfered with their ability to define patent criteria and to issue compulsory licenses to reduce the cost of lifesaving ARVs for their own people.

Over 34 million people worldwide have HIV, of whom 30 million are living in low- and middle-income countries. According to the most recent World Health Organization and UNAIDS estimates, at least 15 million people need treatment now, but only 6.6 million currently have access -- the vast majority provided by PEPFAR and/or the Global Fund.

Founded in 2002, the Global Fund is the world's largest multilateral donor for AIDS, TB, and malaria programs. The Fund is a public-private partnership, supported by multiyear commitments made by G20 and individual philanthropic donors. Due to the global economic crisis, the Global Fund faced a multibillion-dollar gap, and was unable to fully fund some of the proposals submitted last year by organizations and countries with large epidemics to support their prevention, treatment, and care efforts. The lack of funding commitment also lead to the cancellation of the latest round of grants. The organization is now trying to recover after the U.S. banded together with other donors to force the exit of its distinguished executive director, Dr. Michel Kazatchkine, only to have him replaced by an untested and inexperienced retired banker with no experience in global health.

While the Global Fund has had its share of problems, it is addressing them with transparency and commitment. Without full backing by the U.S. and other donor nations, countless lives will be lost. We have already heard of HIV programs not having enough money to enroll new patients who urgently require ARVs and existing patients forced into treatment interruptions. Progress to increase the numbers of people tested for HIV is being threatened because people are hearing that treatment is not available, and the newly diagnosed or newly ill have no place to receive appropriate care.

While administration officials may claim that the proposed half billion dollar cut to PEPFAR will be partly offset by a proposed increase in U.S. support to the Global Fund, what is really happening is a robbing of Peter to pay Paul, as PEPFAR and the Global Fund complement each other, and fully funding each of them is essential to achieving universal access to prevention, treatment, and care.

Battered by the persistent economic crisis, faltering commitment by donors, and changing fashions in global health, the collective global fight against AIDS is wavering. The Obama administration, while long on promises, has routinely come up short on performance. Evidence of impact or even metrics of measurability for the GHI, or the U.S. National AIDS Strategy for that matter, remain elusive.

This past December, on World AIDS Day, the world commemorated 30 years of fighting the epidemic; the administration responded by launching more new initiatives. One is to increase the PEPFAR target to reach a total of 6 million people on ARVs by 2013, and the second is to globally eradicate pediatric HIV by 2015. Both of these goals are laudable, and the administration's announcement was met with much fanfare. Yet in a stunning reversal (or, some may argue, sleight of hand) not three months after making these new commitments, the administration proposed a $563 million cut for next year's PEPFAR budget -- a drastic and ominous cut to make one year before the program's congressional authorization will need to be renewed.

So we are left with the reality that gone seems to be the commitment by the administration to fight AIDS; gone seems to be the enthusiasm and political will by the G20 to achieve universal access; gone -- by attrition or retirement -- are most of the champions of PEPFAR who roamed the congressional halls drumming up support for the program in 2003 and 2008. With the administration's commitment to a third reauthorization of PEPFAR in jeopardy, and many of the Global Fund donors fleeing for the exits, the stage is being set for a global health catastrophe.

Portents of doom aside, there remains a real question about the future of U.S. leadership in the global fight against HIV. Take, for instance, Obama's proposed zero-sum increase of next year's NIH budget, despite his campaign promise before the 2008 election to double that budget over the coming decade. The president is way off track in meeting his promise, which is consequently undermining our ability to translate scientific advances into cures, jeopardizing our nation's long-term status as the global leader in health research, and turning back the clock on the search for an AIDS cure and better treatments for hepatitis C and TB. Further, with looming threats of sequestration ahead -- which could lead to a 9% across-the-board cut for the NIH -- and the growing inflationary burden of research and development activities, flatlining the NIH budget is, in real terms, a cut.

NIH-funded biomedical research has recently led to a number of break-throughs, not only with microbicides and medical male circumcision, but also with the recent finding that antiretroviral treatment reduces the risk of HIV transmission by 96%.
These biomedical advances suggest that by scaling up people on treatment we can turn the tide on the global epidemic. However, in order to do so we must continue to translate the science into applicable interventions, which will require more research, the best and brightest scientific minds, and a long-term robust commitment to funding the NIH.

Finally, negligible increases in Obama's 2013 budget for the Centers for Disease Control and Prevention's (CDC) work to fight the two leading killers of people with HIV -- TB and hepatitis C -- as well as continued insufficient attention to the National HIV/AIDS Strategy and a worsening domestic AIDS crisis in marginalized populations demonstrate that the administration's wavering commitment in the fight against HIV does indeed cut across geographical lines. Increasing division between the domestic and global epidemics in the U.S.-based AIDS advocacy community needs to be reexamined as we fight harder and harder each year for increasingly inadequate pots of funding.

Make no mistake -- reduced spending in the short term will affect progress in the fight against HIV/AIDS in the long term. As we move forward in this election year and continue to educate political leadership, we must remind them what is truly at stake. We must demand less rhetoric and more action, unity for fighting both the global and domestic epidemics, and bolder asks that belie the reality that we are on the front lines of making the invisible visible -- the suffering of millions of people living with HIV/AIDS in the U.S. and around the world.

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